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艺术化的三叉神经痛(精品)课件

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艺术化 三叉 神经痛 精品 课件
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With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 艺术化的三叉神经痛 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三叉神经痛诊断和治疗三叉神经痛诊断和治疗 Diagnostic Approach and Diagnostic Approach and A Review of the Therapeutic Options for A Review of the Therapeutic Options for Trigeminal NeuralgiaTrigeminal Neuralgia With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 资料来源资料来源 • • 循证医学循证医学 – – AAN-EFNS guidelines on trigeminal neuralgia managementAAN-EFNS guidelines on trigeminal neuralgia management:: AAN-EFNS AAN-EFNS 三叉神经痛指南管理三叉神经痛指南管理 – – Practice Parameter: The diagnostic evaluation and treatment of Practice Parameter: The diagnostic evaluation and treatment of trigeminal neuralgia (an evidence-based review)trigeminal neuralgia (an evidence-based review):: 实践参数:三叉神经痛的实践参数:三叉神经痛的 诊断评价和治疗(以证据为基础的评述)诊断评价和治疗(以证据为基础的评述) • • IHS LibraryIHS Library::IHSIHS的图书馆的图书馆 • • BooksBooks – – Adams and Victor’s Principles of Neurology Adams and Victor’s Principles of Neurology ::Adams and Victor’Adams and Victor’《《神经病神经病 学原理学原理》》 – – Wolff’s Headache and other head pains Wolff’s Headache and other head pains ::WolffWolff《《头痛和其他头部的疼痛头痛和其他头部的疼痛 》》 – – The Headaches (The Headaches (OlesenOlesen et al., 2006) et al., 2006) :头痛(奥利森等。,:头痛(奥利森等。,20062006年)年) • • Journals Journals 期刊期刊 = 22 papers = 22 papers 2222个文件个文件 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三叉神经功能与分布 •分布 –I :眼支 –II :上颌支 –III :下颌支 •运动:咀嚼运动 •感觉: –面 –头颅 –牙齿 –口腔与鼻腔粘膜 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 颅神经痛及中枢性面部疼痛颅神经痛及中枢性面部疼痛 1. 三叉神经痛 2. 舌咽神经痛 3. 中间神经痛 4. 喉上神经痛 5. 鼻睫神经痛 6. 眶上神经痛 7. 其他终末分支神经痛 8. 枕部神经痛 9.颈-舌综合症 10.冷刺激性头痛 11.压力所致持续性疼痛, 刺 激或扭曲所致颅神经痛 or 高颈段神经根结构性损伤 12.视神经炎 13.糖尿病性视神经病变 14.带状疱疹病毒感染后头面 部神经痛 15.偏侧性颅痛 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 背景 • 定义:三叉神经痛(Trigeminal neuralgia,TN) – 突然发生 – 单侧性(R:L=5:1) – 刺痛 – 程度严重 – 时间短暂 – 发作性复发 – 分布:三叉神经分布区域内(一支或多支) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 发病年龄发病年龄 • • 特发性(原发性)三叉神经痛:特发性(原发性)三叉神经痛:52-5852-58岁岁 • • 症状性(继发性)三叉神经痛:症状性(继发性)三叉神经痛:30-3530-35岁岁 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三叉神经痛分类 • IHS 2ed分类IHS国际头痛疾病分类第二版(ICHD-Ⅱ)2 – 经典性(Classical TN,CTN) • 原发性(Idiopathic) • 血管卡压性(Vascular compression) – 症状性(Symptomatic TN) • Tumour • MS • 颅底结构异常 • • 根据临床表现 – 典型(Typical)三叉神经痛 – 非典型(Atypical)三叉神经痛 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 病理生理学病理生理学 •经典的三叉神经痛(特发性的与微血管压迫) – 目前尚未发现明确的病因 • 但有可能与临近血管刺激三叉神经节 • 继发脱髓鞘(轴突兴奋性过高) • 自发性发电 •症状性 – 最常见的原因是CN V的感染 – 各种结构性改变:如肿瘤 – 与MS相关的脱髓鞘 • 4% MS病人有 TN • 2% TN患者患MS With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 脱髓鞘疾病脱髓鞘疾病 ( (轴索兴奋性增高轴索兴奋性增高) ) • • 多发性硬化多发性硬化 (MS) (MS) – – 三叉神经传入支神经根髓鞘脱失三叉神经传入支神经根髓鞘脱失 • • 神经损伤后神经损伤后 – – 外伤后外伤后 – – 牙科手术后牙科手术后 • • 下颌骨创伤后下颌骨创伤后 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三叉神经节受压三叉神经节受压 • • 血管血管 – – 基底动脉分支不清及动脉粥样硬化基底动脉分支不清及动脉粥样硬化 – – 基底动脉瘤基底动脉瘤 • • 小脑桥脑角小脑桥脑角 (CPA) (CPA) 占位占位 – – 脑膜瘤脑膜瘤 – – 髓索瘤髓索瘤 – – 神经鞘瘤神经鞘瘤 – – 转移瘤转移瘤 ( (鼻咽癌鼻咽癌) ) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 脱髓鞘疾病脱髓鞘疾病 ( (轴索兴奋性增高轴索兴奋性增高) ) • • 感染后感染后 – – 带状疱疹带状疱疹 – – 鼓室乳突炎鼓室乳突炎 – – 牙源性牙源性 ( (微小脓肿和牙髓变性)微小脓肿和牙髓变性) • • 炎症性炎症性 – – 结缔组织病结缔组织病 ( (干燥综合征干燥综合征) ) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 临床表现临床表现 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 持续疼痛与发作性疼痛 全天候药物 持续的疼痛持续的疼痛 发作性的疼痛 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 临床表现和体征临床表现和体征 • • 发作性、剧烈、短暂、电击样疼痛、撕裂样疼痛、刀刺痛发作性、剧烈、短暂、电击样疼痛、撕裂样疼痛、刀刺痛 ,,“ “又红又热的针扎感又红又热的针扎感”,“”,“闪电样闪电样 • • 一般为单侧三叉神经区域受累,第二、三支分布区域多见一般为单侧三叉神经区域受累,第二、三支分布区域多见 ,常有扳机点,常有扳机点 . . 无明确三叉神经感觉和运动受损的体征无明确三叉神经感觉和运动受损的体征 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 诊断思路 颜面部疼痛颜面部疼痛 病史病史 体格检查体格检查 (PE)(PE) 神经系统检查神经系统检查 (NE)(NE) 辅助检查辅助检查 头颅头颅 MRI / MRAMRI / MRA 头颅头颅 CT / CTACT / CTA 电测听电测听 诱发电位诱发电位 心脏检查心脏检查 临床临床症状症状相关相关 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society How often does routine neuroimaging (CT, MRI) identify a cause (excluding vascular contact) of TN? With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三叉神经痛:表皮样肿瘤 45岁,3年典型三叉神经痛 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三叉神经痛:听神经瘤 30岁,男性,一侧耳聋伴有三叉神经痛 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三叉神经痛:三叉神经肿瘤 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三叉神经痛与血管压迫 血管压迫三叉神经节没有血管压迫三叉神经节三叉神经节受到的刺激是 由于神经血管的压迫 极度活跃的三叉神经核 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 鉴别诊断鉴别诊断 1.1.脱髓鞘脱髓鞘 (MS) (MS)  神经内科神经内科 2.2.小脑桥脑角肿瘤小脑桥脑角肿瘤  神经外科神经外科 3.3.鼻咽部及鼻旁窦疾病鼻咽部及鼻旁窦疾病  耳鼻喉科耳鼻喉科 4.4.牙科疾病牙科疾病  牙科牙科 5.5.单纯疱疹病毒感染单纯疱疹病毒感染  神经内科神经内科 6.6.特发性特发性 药物治疗药物治疗  神经外科神经外科 7.7.不稳定型心绞痛不稳定型心绞痛 心脏病学心脏病学 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society CTN与STN的鉴别诊断 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society CNT与STN的鉴别诊断 •提示STN(B级证据) – 感觉损害 – 双侧受累 – 三叉神经反射障碍 •不能够区别STN与CTN(B级证据) – 起病年龄较轻 – 三叉神经第一支受累 – 药物治疗反应不佳 – 三叉神经诱发电位异常 AAN-EFNS guidelines on trigeminal neuralgia management,European Journal of Neurology 2008, 15: 1013–1028 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 治疗手段治疗手段 • • 药物治疗药物治疗 – – 抗癫痫药物抗癫痫药物 – – 非抗癫痫药物非抗癫痫药物 • • 手术治疗手术治疗 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 药物治疗 • 卡马西平治疗TN的疗效确切(A级) European Journal of Neurology 2008, 15: 1013–1028. • 奥卡西平控制CTN疼痛(B级) • 加巴喷汀、拉莫三嗪、匹莫齐特可以考虑用于控 制CTN疼痛(C级) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 巴氯芬 • Baclofen(巴氯芬) superior to placebo :巴氯 芬优于安慰剂 – in reducing the number of painful paroxysms:在 减少疼痛的发作次数上 – (Class II) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三叉神经经痛治疗疗的证证据强度 药药 物手 术术 强证据中等强度证 据 初级证据短程使用 初级证据 手术放射治疗 卡马西平加巴喷丁拉莫三嗪磷苯妥英微血管减压术伽马刀 奥卡西平苯妥英普瑞巴林利多卡因经皮神经根切断 巴氯芬肉毒毒素舒马普坦球囊加压 经皮神经阻滞 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三叉神经痛治疗流程 一线药物:卡马西平/奥卡西平 二线药物:加巴喷丁,普瑞巴林,苯妥英, 拉莫三嗪,抗抑郁药 2-3个药物无效,推荐到专业机构治疗 干预方法的选择 周围神经阻滞微血管减压经皮手术放射治疗 PRFR: Percutaneous radiofrequency rhizotomy BCR: Balloon compression rhizotomy PRGR: Percutaneous retro-Gasserian rhizotomy GKR; Gamma knife radiosurgery LINAC:Linear accelerator radiosurgery 非抗癫痫类药物
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